System for communication of health care data

ABSTRACT

An apparatus for communicating health care data from a sender to a receiver is provided. The apparatus has a first computer system, a second computer system, and a rules engine. The first computer system has health care data stored therein. The second computer system is in operable communication with, and is configured to extract the health care data from, the first computer system. The rules engine normalizes the extracted health care data to a predefined format. The rules engine defines a plurality of health care data fields in the predefined format, as well as a plurality of relationships between fields of normalized data.

RELATED APPLICATIONS

This is a divisional application of U.S. application Ser. No.11/603,399, filed Nov. 22, 2006, which was a continuation of U.S.application Ser. No. 10/381,158, filed on Mar. 21, 2003, entitled“System for Communication of Health Care Data,” which was the NationalStage of International Application No. PCT/US01/42618, filed Oct. 11,2001, entitled “System for Communication of Health Care Data,” whichclaimed the benefit of Provision Application No. 60/239,860 filed onOct. 11, 2000, entitled “Apparatus and Method for EstablishingConnectivity.” To the extent not included below, the subject matterdisclosed in these applications are hereby expressly incorporated intothe present application.

FIELD OF THE INVENTION

The present invention relates generally to a computerized system thatestablishes connectivity between interested parties in the health careindustry for the administration of health care services. Moreparticularly, the present invention relates to a system for thenormalization of health care data of various formats and exchanging thedata in normalized form between insurers and participants, such asproviders, patients, and employers.

BACKGROUND AND SUMMARY

Health care can be defined as an information industry; most of the timeand money spent in procuring and delivering health care is spentcreating, retrieving, or using information. Expenditures on health careinformation technology support, for example, have increased from aboutone billion dollars in 1990 to a projected $20 billion in 2000. Yet,even with these investments, it is believed that almost half of allcurrent health care expenditures continue to be for non-patient careactivities; a major share of which is for non-automated informationsupport.

Resources having to be directed to non-patient care activities have beenendemic in the health care industry since the 1960's. During the 1990's,however, with the demise of Medicare Cost Reimbursement and the rise ofmanaged care, there has been a major shift in attitude and focus amongboth physicians and patients. New rules now govern the delivery ofmedical care and the payment for such care. Whether via preferredprovider arrangements, capitation arrangements of endless variety, casemanagement, or “best practice” enforcement, determining what care isallowed, what will be paid by whom, and making sure that the appropriateinformation is submitted to ensure that the process works are nowconsuming a major share of both time and financial resources ofinsurers, providers, and patients.

Health care participants, like providers and employers, regularly dealwith a number of health care plans from various health insurers. Theseparticipants, however, can only obtain information from the insurancecompanies in limited ways, often making the acquisition of suchinformation quite burdensome. Participants usually only have thetelephone, fax, or letter available as a means of communication with theinsurers.

Particularly vexing is the timely availability of information frominsurers regarding financial transactions, such as eligibility, claims,and benefits, and basic patient-related information, such as medicaltests and prescriptions. For example, a provider may seek informationfrom an insurer via a submission form or telephone call to that insurer.In many cases, however, such information is sought or received after thecare has been delivered and the patient has left the provider's office.This may result in the delivery of services that are not authorized orcovered by the patient's insurer, or may result in other consequencesthat might impact the type or cost of the services provided.

Another reason for these difficulties is the recent expansion of the“payor” community. At one time, payors consisted of the government (bothfederal and state) and large insurance companies. Now, a complex arrayof self-insured plans, IDN's, IPA's, and PPO's, undertaking full orpartial capitation, insurance carve-outs, and the like have radicallyincreased the number of users of, and the need for, current informationregarding insureds. Most of these entities, both small and large, dospend considerable sums on information systems. Yet, because of theextent of manual processing that exists despite these systems, costs perclaim remain substantial.

In addition, payors incur the wrath of their providers and patients bydesigning complex rules that are difficult or perceived as impossible toadminister or follow. Though contrary to this perception, payors do havean interest in providing timely information to providers, patients,employers, and other participants. Still, a significant percentage of aprovider's claims are rejected often because they do not comply with allof the rules. These claims require resubmission, telephone calls, andother expensive manual interventions. The dollar costs for this currentprocessing scheme are high. In fact, an entire clearinghouse industryhas been developed to provide eligibility (but not benefits)verification services to providers for a fee. Many of the requestedverifications, however, cannot be performed at all by suchclearinghouses, and those that are performed are often unacceptablycumbersome and, thus, too expensive.

Referral authorizations are often even more complex than claims and suchauthorization services are generally not available via traditionalclearinghouses. Each time a provider writes a prescription, for example,it is written against a formulary specific to that patient's health careplan established by their insurer. Because there are so manyformularies, drug prescriptions, too, are often rejected for payment,causing additional work for both the provider and the patient.Similarly, medical tests must be sent to laboratories contracted tosupport a particular plan, and are reimbursed only when matching complexmedical necessity rules.

Many providers do have practice management systems that track encountersand manage billing. None of these systems, however, have thesophistication to accomplish the task of providing all of theinformation from all the various health insurers in such a cogent formthat can be useful to the provider.

Not only providers, but patients, too, spend a majority of their timeinteracting with the health care system engaged in non-health careactivities. This “wasted” time is virtually all related to schedulingappropriate interventions, to waiting for information or services, or toobtaining authorization, reimbursement, or other information for desiredor required health care.

The internet has emerged as a major source of health care informationfor the public. A substantial portion of internet users use it forhealth care information or management. Specifically, patients search theinternet for medical information and answers related to their area ofconcern, In fact, it is becoming common for a patient to enter aphysician's office armed with printouts and long lists of questions andrecommendations from web pages on the internet.

Unfortunately, even with the connectivity the internet provides,information exchange between insurers and patients is lacking. Most ofthe information available to patients from their insurer is on anautomated basis from databases related to either general health careliterature or to specific normality support groups. A critical aspect ofthe patient's health care program, however, is not only knowledge of thenormality or support groups, but also what their insurer's health careplan provides as treatment options for that normality, eligibilityinformation, referral authorization, claim submission and payment,testing, and medications. As discussed, these functionalities are toocomplicated for the current system to handle in an automatedenvironment. Personally-referenced information linked to an individualpatient's provider and health care plan is generally unavailable,because that data exists in several databases often each in a different,incompatible format, requiring human intervention to extract and processthe data. The patient's current solution is, thus, an endless number oftelephone calls at a high cost in dollars, time, and frustration.

A reason for such incompatibility is that each database served theindividual needs of those using the data before such a time whenconnectivity between databases was a consideration. The consequence ofhaving different databases of different formats is that it is notpossible to provide a central repository of homogenized data readable byany variety of computers. It is this incompatibility that prevents widespread connectivity between insurers and participants.

Transliterating and interfacing programs are known in the art. Programsthat take data in one format can be translated and read by a computer ofa different format. Such transliterating, however, only shifts data froma field of an incompatible format to a target field of a new format. Itcannot determine whether the data of the incompatible format is beingtransferred to the correct target field. Normalization or remodeling ofthe data not only transfers the data, but also determines the meaning ofthe data and puts that data in the correct field.

It would, therefore, be beneficial to provide a system with whichinsurers may communicate with providers, patients, etc., to provideinformation about a particular health care plan either before, orcontemporaneously with, the patient's visit to the provider, regardlessthe lack of compatibility of the databases. It would be furtherbeneficial if this system of communication spanned a variety of insurersso the provider, for example, may communicate with any plan in which thepatient participates. It would also be beneficial for providers to havean automated system of determining eligibility and benefits, receivingauthorizations and pre-certifications, submitting claims, obtainingreimbursements, and adjudicating claim problems through thenormalization of data of the incompatible databases.

Accordingly, an illustrative embodiment of the present disclosureprovides an apparatus for communicating health care data from a senderto a receiver. The apparatus comprises a first computer system, a secondcomputer system, and a rules engine. The first computer system havinghealth care data stored therein. The second computer system is inoperable communication with, and is configured to extract the healthcare data from the first computer system. The rules engine normalizesthe extracted health care data to a predefined format. The rules enginedefines a plurality of health care data fields in the predefined format,as well as a plurality of relationships between fields of normalizeddata.

Further embodiments may include the first computer being a plurality ofcomputers each having portions of the health care data stored thereon.The apparatus may also comprise a third computer system, in operablecommunication with, and configured to receive the normalized data from,the second computer system. The rules engine may determine whether thethird computer is authorized to receive the health care data.

Another illustrative embodiment provides a method for communicatinghealth care data from one computer system to another. The methodcomprises the steps of storing health care data in a first computersystem; extracting health care data from the first computer system andcommunicating the extracted data to a second computer system;normalizing the extracted data to a predefined format in accordance witha rules engine that defines a plurality of health care data fields inthe predefined format and a plurality of relationships between fields ofnormalized data; and communicating the normalized data to a thirdcomputer system.

Further embodiments of the illustrative method may include the firstcomputer system comprising a plurality of computers, wherein the storingstep includes storing health care data in more than one of saidcomputers. Also, the third computer system comprises a plurality ofcomputers. The health care data exists across a plurality of databasessuch that each of the plurality of databases are in operablecommunication with the second computer system.

Another illustrative embodiment provides a system of exchanging healthcare data between a sender and a receiver. The system comprises a sendercomputer, an intermediary computer, a rules engine and a receivercomputer. The sender computer stores the health care data. Theintermediary computer is in operable communication with the sendercomputer and is configured to extract the health care data. Theextracted data is normalized to a predefined format, creating normalizeddata pursuant to a rules engine. The rules engine defines each field ofthe health care data and converts each field to a corresponding field inthe predefined format. The rules engine also defines how the normalizeddata should relate to each other pursuant to predetermined instructions.The receiver computer is in operable communication with the intermediarycomputer. The receiver computer receives the normalized data subjectedto the second rules engine.

Further embodiments may include the sender computer being a plurality ofcomputers each having portions of the health care data stored thereon.The rules engine may determine whether the receiver computer isauthorized to receive the health care data. When the receiver is ahealth care provider, the normalized data exchanged between the senderand receiver may be chosen from a group comprising eligibility/benefitdisplay, member roster, claim submission, provider lookup, formularylookup, diagnosis code lookup, procedure code lookup, access health planinformation online, communicate with a health plan on-line, communicatewith patients on-line, patient-centric view of data across severalhealth plans, order generation and tracking, results review and release,result printing, prescription writing, medication profile for eachpatient, access to patient's personal health record based on patientapproval, personalized medical and health care content integration, bothcontext-specific and on demand, e-commerce integration: office, medicaland health-related product awareness and buying capabilities, email,practice management system subscription, support disease management, andphysician credentialing subscription. When the receiver is an employer,the normalized data exchanged between the sender and receiver is chosenfrom a group comprising group eligibility, group enrollment, enrollmentchanges, formulary lookup, e-commerce integration, access from healthplan web site or direct access via URL, personalized contentintegration, both context-specific and on demand, e-commerce integrationand health care-related product awareness and buying capabilities.

When the receiver is a patient, the normalized data exchanged betweenthe sender and receiver is chosen from a group comprising identificationcard requests, address changes, provider directory inquiries,personalized health information based on an interest profile, diagnosisinformation, relevant articles and patient education materials,communications from health care providers and health care plans, lab andradiology results, scheduled appointments with a health care provider,prescription refills, personal health records, eligibility/benefitinformation, claim information, referral and authorization informationand status, provider lookup, family history, medication profile andformulary lookup.

Another illustrative embodiment of the present invention provides asystem of normalizing health care data for transfer between an insurerand a participant. The system comprises an insurer system, anintermediary system, and a participant system. The insurer system isconfigured to maintain at least one database comprising the health caredata. The intermediary system is operatively connected to the insurersystem and to the database, configured to extract the health care datafrom the database of the insurer system, and store the health care datain a staging database as extracted data. The extracted data isnormalized to a predefined format, creating normalized data pursuant toa rules engine that defines each field of the extracted data in thepredefined format. The rules engine also defines how the normalized datarelates to each other pursuant to predetermined instructions. Theparticipant system is in operable communication with the intermediarysystem, and is configured to receive the normalized data subject to therules engine.

Further embodiments of the illustrative system may include the at leastone database being a plurality of databases, such that the intermediarysystem is operatively connected to the plurality of databases. Inaddition, the participant system may transmit a request that is sent tothe intermediary system that determines which health care data is to beextracted and normalized in order to respond to the request. Theparticipant system may also transmit the request, and the intermediarysystem may transmit the normalized data over the internet. The rulesengine may define the relationships among the normalized data pursuantto predetermined instructions to determine a response to the request.The intermediary system may also comprise an error data system thatremoves extracted data identified as invalid when the extracted data isnormalized. The extracted data identified as invalid is then corrected,reintroduced, and is normalized. The intermediary system may furthercomprise an audit database to track the activity of the intermediarysystem.

Another illustrative embodiment of the present invention provides asystem of health care management of medical testing administrationbetween an insurer, a medical laboratory, and at least one health careparticipant. The system comprises a participant computer, an insurerprocessing system, a rules database, and a laboratory computer. Amedical test request is made at the participant computer pursuant to afirst predetermined format. The insurer processing system is operativelycoupled to the participant's computer, and is through which the medicalrequest is transferred. The processing system is operatively coupled tothe rules database to approve the medical test request pursuant topredetermined criteria. The laboratory computer is operatively coupledto the processing system and receives the medical test request ifapproved by the rules engine. Results of the medical test aretransmitted from the laboratory computer to the processing system. Theresults are further transmitted to an insurer computer that isoperatively coupled to the laboratory computer and to participant'scomputer.

Further embodiments of the illustrative system may include theprocessing system converting the results of the medical test to a secondpredetermined format readable by a database stored on the insurercomputer. In addition, at least one health care participant may bechosen from a group comprising from a health care provider, an employer,and a patient. Furthermore, the medical test request and the results ofthe medical test may be transmitted through the internet.

Additional features and advantages of the system will become apparent tothose skilled in the art upon consideration of the following detaileddescriptions exemplifying the best mode of carrying out the system aspresently perceived.

BRIEF DESCRIPTION OF THE DRAWINGS

The illustrative system will be described hereinafter with reference tothe attached drawings which are given as non-limiting examples only, inwhich:

FIG. 1 is a diagrammatic view of a system for normalization of healthcare data and the exchange of same between several health care insurersand various health care participants;

FIG. 2 is a diagrammatic view of the data processing system for thesystem of normalization shown in FIG. 1;

FIG. 3 is a diagrammatic view of the data extraction and business objectsub-systems for the system of normalization shown in FIG. 1;

FIG. 4 is a diagrammatic view of a system of health care management formedical testing between health care insurers and participants;

FIGS. 5A-5C show an example portal from which a patient can obtain andsubmit information.

FIGS. 6A-6D show an example user interface for health care providers toorder and view medical tests over the Internet; and

FIG. 7 shows an example user interface in which a health care providercan submit a prescription to a pharmacy over the Internet.

Corresponding reference characters indicate corresponding partsthroughout the several views. The exemplification set out hereinillustrates an embodiment of the invention, and such exemplification isnot to be construed as limiting the scope of the invention in anymanner.

DETAILED DESCRIPTION OF THE DRAWINGS

An illustrative embodiment of the invention, such as that shown in FIG.1, comprises a system 2 which includes a plurality of database sets 4,6, 8 offered by a variety of insurers 11. It is appreciated that eachhealth care database set 4, 6, 8 represents an insurer's databaseprocessing system or series of processing systems and databases. Forexample, database sets 4, 6, or 8 may each represent a conventionalcomputer system, a server, a local area network (LAN), a legacy, orother computer system storing one or more databases. It is contemplatedthat to transmit data, either the system as it exists is capable ofdoing so, or a system is added to either database sets 4, 6, or 8 toperform this function. It is further contemplated that each of databasesets 4, 6, 8 may represent a single database or a plurality ofdatabases, each of which may be of any variety of database formats orlanguages.

For the purposes of this application, it is contemplated that referenceto the term “insurer,” as used herein for insurers 11, is forillustrative purposes only. Such a term includes health insurancecompanies, but also includes health maintenance organizations,self-insured entities, disease management organizations, capitatedhealth care providers, Medicare agencies, as well as any otherorganization that might store or manage health care data. The term“insurer” is not to be construed as being limited in scope to onlyhealth insurance companies or other “payors.”

Conventionally, health care data is stored on an insurers' computer orseries of computers in several databases, each of which often being in aunique format, with each database format being incompatible with otherdatabase formats. For example, one insurer may have their health caredata stored in one format, and a second insurer may have their healthcare-related data stored in a second format that is not compatible withthe one format. Additionally, and more problematic is that, even withinthe same insurer's 11 system, eligibility data, for example, may existin a database of one particular format, developed to suit the needs ofits users at the time, whereas, the claims data, for example, may bestored in another database in a format that suits the needs of thoseusers, but with its format being incompatible with the format of theeligibility data. In either example, it is contemplated that in thepresent invention, health care data of any format is normalized into acommon format, and distributed through a common network, like internet12, to a health care participant 13, who uses the normalized data toconduct health care-related transactions and tasks. It is furthercontemplated, and to be discussed further herein, that various levels ofaccess and security can be provided to assure that those participants 13accessing the normalized data are authorized to access only that datapredetermined as necessary and appropriate for their particular use orneed.

As FIG. 1 shows, data from each database set 4, 6, 8 can be transmittedto a data processing system 10 that normalizes the data into a formatreadable by particular health care participants 13. More specifically,the data is transmitted over the internet 12, which is operativelyconnected to and read by participants' 13 computer(s) or terminal(s).Such participants 13 illustratively include providers 14, employers 16,and patients 18, or any combination thereof. It is contemplated thatparticipants 13 can further include any other interested party that canrequest data or information from an insurer, including other insurersand disease management organizations, for example.

It is contemplated that the transmission of data from database sets 4,6, or 8 is initiated by any of the participants 13 submitting a request22 through a computer or computers. Request 22 is transmitted throughthe interne 12 to data processing system 10 which retrieves theappropriate data from the appropriate database set or sets of either 4,6, or 8. That data is normalized to a common format, at which point aresponse 24 to the request 22 is made. For example, a health careprovider 14 may place a request 22 on behalf of an insured to authorizepayment for a medical procedure. In this example, it is presumed thatthe data required to formulate a response 24 exists collectively oneligibility, benefits, and claims databases that illustratively exist ondatabase set 4. Data processing system 10, in order to prepare aresponse 24, determines and extracts which data is necessary from thedatabases. System 10 then normalizes the data into a homogenous format,and then determines what the nature of the response should be. In thisexample, response 24 should be to either authorize or deny payment forthe medical procedure. System 10 uses the normalized data to determinethe response, which is then transmitted to provider 14, thus, completingthe transaction. It is contemplated that system 2 may comprise anynumber of insurers 11 or participants 13. Specifically, data processingsystem 10, as will be discussed further herein, is able to connect andmanage transactions between a single or plurality of participants 13with any insurer or plurality of insurers 11.

It is further contemplated that system 2 will provide health careparticipants 13 with a variety of health care transaction optionsreferred to generally in the form of requests 22 and responses 24between participants 13 and insurers 11. Examples of transactionsavailable to health care providers 14 are: eligibility/benefit display,member roster, claim submission, provider lookup, formulary lookup,diagnosis code lookup, procedure code lookup, access health planinformation online, communicate with a health plan on-line, communicatewith patients on-line, patient-centric view of data across severalhealth plans, order generation and tracking, results review and release,result printing, prescription writing, medication profile for eachpatient, access to patient's personal health record based on patientapproval, personalized medical and health care content integration, bothcontext-specific and on demand, e-commerce integration: office, medicaland health-related product awareness and buying capabilities, email,practice management system subscription, support disease management, andphysician credentialing subscription.

As further example, the following are specific records and fields forhealth care transactions between providers 14 and insurers 11 thatutilize normalized data:

Record: Summary

-   -   Fields:

Activity for (date)

Referrals

Claims

Test Results

Members

Update State for Americas Health

Benefit Records

Claim Records

Patient Records

Provider Records

New Just For You

Record: Eligibility

-   -   Fields:

Today's Patients

Patient Search

Sex

Coordination of benefits

Medicare data

Add to patient list

Name

From Date

To Date

Birth date

Member ID

Relation

PCP

Address

City

State

Zip

Current Benefit

Group

Carrier

Benefit Plan

Record: Claim Status

-   -   Fields:

Patient Name

From Date

To Date

Claims

Claim Number

Status

Provider Name

Patient Name

Member Number

Billed Amount

Patient Responsibility

Paid Amount

Date of Service

Record: Claim Detail

-   -   Fields:

Member

Provider

Diagnosis

Description

Line number

DOS

CPT

Description

Modifier

Location

Units

Status

Billed

Allowed

Copay

Coinsurance

Deductible

Paid

Totals

Record: Explanation of Payments

-   -   Fields:

Line Number

Status Description

Explanation

Check/Date

Record: Select Specialist

-   -   Fields:

Address

City, State, Zip

Handicap Access

Office Hours

Contact

Phone

Fax Phone

Phone After Hours

Sex

Birth Date

Specialty

Second Specialty

Accept Patient

Primary Care

Board Cert

Languages

Hospitals

Hospital Privileges

Networks

Record: Add Claims

-   -   Fields:

Health Insurance

Insured's ID Number

Patient Last Name

First Name

Middle Name

Patient's Address 1

Address 2

City

State

Zip

Patient's Phone

Birth date

Gender

Relationship to Insured

Marital Status

Patient Employment Status

Condition Related to Job

Con. Rel. to Auto Accident

Cond. Rel. to Other Accident

Insured's Last Name

First Name

Middle Name

Gender

Birth date

Insured's Address 1

Address 2

City

State

Zip

Phone

Insured's Group or FECA Number

Insured's Employer/School

Insured's Insurance Name

Referring Physician Name

Referring Physician ID

Outside lab

Outside Lab Charges

Medicaid Resub Code

Medicaid Orig.

Prior Auth. Number

Diag Codes

Item

Date From

Date To

Place

Type

Procedure

Mod1

Mod2

DX Ind.

Charges

Days/Units

Patient

Provider

From Date

To Date

Diagnosis 1

Diagnosis 2

Diagnosis 3

Diagnosis 4

Procedure Line

CPT

Description

Amount

Dx pointer

Other Errors

Total Amount

Billed

Allowed Amount

Copay Amount

Withheld Amount

Writeoff Amount

Predicted Payment

Record: Referral Status

-   -   Fields:

Referral Number

Patient (Member ID)

Valid from (months)

Referred by

Referred to

Patient List

Referred by

Referred to

Referral Number

Status

Record: Add Referrals

-   -   Fields:

Today's Patients

Patient Search

Specialists

Specialist Search

Providers

Diagnosis

Patient

Specialists

Provider

Diagnosis

Start Date

Months Valid

Visits Requested

Reason

Record: Procedure and Diagnosis Data

-   -   Fields:

Diag Number

Diagnosis Name

Proc Code

Procedure Name

Visits Allowed

Patient

Patient Search

Referred to

Specialist Search

Referred by

Diagnosis

Start Date

Exp Date

Visits Requested

Remarks

Services Requested

Authorized Ancillary Services

Record: Diagnosis Codes

-   -   Fields:

Diagnosis Code

DX Code

Diagnosis Code Description

Record: Procedure Codes

-   -   Fields:

Procedure Codes

Procedure Code

Procedure Description

Age From

Age To

Sex

Location Code

Record: Drug Therapeutic Class Listing

-   -   Fields:

Therapeutic Class

Class Description

Count of Drugs in this Class

Record: Formulary List by Therapeutic Class

-   -   Fields:

Drug Name

Generic Name

Drug Class

Therapeutic Class

NDC

Record: Write Prescription

-   -   Fields:

Today's Patients

Patient Search

Providers

For

Medication

Dispense

Refill

Sig: Take

Sig: For

Instructions

Select Pharmacy

Record: Medication Profile

-   -   Fields:

Type

Medication

Dose

Frequency

Reason

Status

Record: Discontinued Medications

-   -   Fields:

Type

Medication

Dose

Frequency

Reason

Status

Record: Allergies

Allergen

Reaction

Date Started

Record: Medical Test Orders

-   -   Fields:

Patient ID

Patient Name

Provide ID

Provider Name

Location

Lab Name

Dx

Action

Battery

Test

ID

Type

Volume

Date

Time

Collected By

Chemistry

Hematology

Toxicology/Therapeutics

Microbiology/Virology

Immunology/Serology

Urinalysis/Fluids

Procedure

When

Priority

Specimen

Alert

Record: Results

-   -   Fields:

Status

Order number

Test Procedure

Alert

Order Date

Facility

Patient

Provider

Date/Time

Procedure

Status

Indicator

Date/Time

Performed

Specimen Number

Type

Status

Result

Value

Desired Range

Each field listed above represents data that can exist anywhere ondatabase sets 4, 6, or 8, and be in any format or language. If anyrequest 22 is made which calls up one or more of the above records, dataprocessing system 10 searches, extracts, and normalizes the data so itappears in the correct field in the record. It is appreciated thatprovider 14 may change the data, if necessary, and transmit it backthrough internet 12 and data processing system 10 to be stored on theappropriate database set 4, 6, or 8.

Examples of transactions available to employers 16 are: groupeligibility, group enrollment, enrollment changes, formulary lookup,e-commerce integration, access from health plan web site or directaccess via URL, personalized content integration, both context-specificand on demand, e-commerce integration: human resource, business (e.g.,office supplies) and health care-related product awareness and buyingcapabilities.

Again, as a further example, the following are specific records andfields for health care transactions between employers 16 and insurers 11that utilize normalized data:

Record: Open Enrollment

-   -   Fields:

Health Insurance

Employer Group Number

Last Name

First Name

Middle Name

Employee Address 1

Address 2

City

State

Zip

Home Phone

Work Phone

Primary Language

Birth date

Gender

Social Security Number

Primary Care Physician

Established Patient

Dependent Last Name

First Name

Middle Initial

Birth date

Gender

Relationship

Social Security Number

Primary Care Physician

Established Patient

Effective Date

Hire/Rehire Date

Other Health Care Policy

Name and Address of Insurer

Effective date of other coverage

Policy Holder's Last Name

First Name

Middle Name

Policy/Group Number

Covered by Medicare

Medicare Number(s)

Health insurance within the last 18 months

If yes, type of coverage: group, individual, COBRA, Medicare/Champus,Conversion or Other

Reason coverage was terminated

Read and Agree to Authorization Statement

Record: Enrollment-Changes

-   -   Fields:

Health Insurance

Employer Group Number

Last Name

First Name

Middle Name

Employee Address 1

Address 2

City

State

Zip

Home Phone

Work Phone

Primary Language

Birth date

Gender

Social Security Number

Primary Care Physician

Established Patient

Term Member

Dependent Last Name

First Name

Middle Initial

Birth date

Gender

Relationship

Social Security Number

Primary Care Physician

Term Dependent

Hire/Rehire Date

Effective Date

Change Reason

Name

Enrollment Type

Remarks

Examples of transactions available to patients 18 are: identificationcard requests, address changes, provider directory inquiries, andpersonalized health information based on the member's interest profile,as well as diagnosis information from health plan administrative andclinical information, relevant articles and patient education materials,communications from health care providers and health care plans, lab andradiology results to patients online, scheduled appointments with ahealth care provider, referral status, prescription refills, educationmaterials, personal health records so it can be maintained in his or hercomprehensive health history online for physician reference, vieweligibility/benefit information, view claim information, view referraland authorization information, provider lookup, personal health record,family history, medication profile, formulary lookup, and communicationsbetween member and provider.

By way of another example, the following may be performed on-line by thepatient:

-   -   PCP changes    -   Identification card request    -   Address changes    -   Provider directory inquiries    -   Personalized health information! Based on the member's interest        profile as well as diagnosis information from health plan        administrative and clinical information, relevant articles and        patient education materials will be available in the “News Just        For You” section.    -   Important communication from health care providers and the        health plan! Physicians will have the capability to release lab        and radiology results to patients on-line. Office staff can        notify patients of their scheduled appointments. In addition, a        member will receive information on health plan wellness programs        and benefit changes that are relevant to that member.    -   Referral status is accessible to members on-line! This        eliminates the time members spend tracking referral status.    -   Prescriptions can be refilled on-line.    -   A list of all prescribed and OTC medications can be maintained        on-line for review.    -   Patient education materials are available to advise the member        of drug warnings for his or her prescriptions.    -   Personal health records can be maintained on-line! A member can        maintain his or her comprehensive health history on-line for        physician reference.    -   Physician office visits can be scheduled on-line!

In some embodiments, all sources of information (multiple health plans,labs, etc.) are integrated into a single patient referenced database.For example, both providers and patients could use the same databasewith different views. In some cases the system 10 may provide a healthportal for patients. The portal may provide personalized healthinformation based on a patient's claims history, as well as ancillary(lab and pharmacy) information, and business-to-consumer e-commerceincluding access to Plan information such as eligibility and claimstatus. Because of the unique advantages offered to patients, thispatient base can cost effectively be turned into a large number ofregistered users in a short period of time. In some cases, relevantarticles and patient education materials may be available based on thepatient's interest profile, as well as diagnosis information from healthplan administrative and clinical information. By way of another example,patients may benefit from health promotion and prevention programs leadby their health plans. For example, patient education about routinemammograms can be provided to the patients meeting target criteriaimpacting medical management, disease management, and NCUA measurements.

The system's 10 ability to provide personalized information through theportal provides a personalized perspective on patient's health, whichtends to hold patient's attention. For patients, this intelligent healthcare portal becomes the ultimate personalized health site combining bothpersonalized health information based on an individual's claims history,as well as available ancillary (lab, pharmacy, etc.) information andbusiness-to-patient e-commerce, including access to client information,such as eligibility and claims' status. Because of the unique advantageoffered to patients, the patient audience can be cost effectively turnedinto a large number of registered users in a short period of time. Insome cases, patients may view communications from physicians through theportal. FIGS. 5A-5C show an example portal from which a patient canobtain and submit information.

The personalized health record typically includes family history,medical profile, test and exam results released by the provider to thepatient. The information in the personalized health record may only bereleased to viewers authorized by the patient. Neither the insuranceproviders nor family members will have access to the patient's medicalinformation unless the patient specifically authorizes access. As usedherein, the terms “patient,” “consumer” and “member” are usedsynonymously.

The architecture of the data processing system 10 is shown in FIG. 2.Each of the database sets 4, 6, 8 is operatively connected to dataconnectivity sub-system 20. The data connectivity sub-system 20 isconfigured to receive the different types of connections used betweenthe various computer systems which store the database sets 4, 6, 8. Itis appreciated that, in other embodiments, a separate data processingsystem 10 may be provided at the site of each of the database sets 4, 6,8 such that each data processing system 10 is dedicated to manage andnormalize the data, as discussed further herein, as well as manageserver-to-server communications for a single database set.

The data extraction sub-system 28 is also depicted in FIG. 2. Sub-system28 manages the integration of the often plurality of databases. The dataextraction sub-system 28, as further discussed in reference to FIG. 3,also includes logic to manage data access from the several databases ofdatabase sets 4, 6, 8. An enterprise master person index (“EMPI”) 30 isoperatively coupled to data extraction sub-system 28. The EMPI 30presents a cross-database view of all the insureds within system 2. Italso manages the proper identification of providers 14, employers 16,connected patients 18, as well as other entities having uniqueidentities on an as-needed basis. An indices database 32 is supported byEMPI 30. Specifically, the indices database 32 stores indices whichserve as a basis for relating the identification data to each other. Theindices database 32 is typically built upon and maintained by the EMPI30.

The business object sub-system 34 contains the logic rules that drivesthe normalization of data and use of same between insurers 11 andparticipants 13. To provide such capabilities, a variety of processesmay be supported in any particular situation. Illustratively, suchprocesses may include, but are not limited to, rules-based evaluation ofentered data for referral authorizations and admissionpre-certifications; proxy or actual adjudication of claims submitted byproviders, with concomitant delivery of funds to insurers 11 andbenefits explanations to patients 18; sorted lists of providers 14,employers 16, and patients 18; and graphical displays of laboratoryresults and integrated claims-driven health records for patients 18.

The content/e-commerce sub-system 36 adds third party capabilities tothe data processing system 10. The content portion of sub-system 36provides management and integration of third party affiliated content,such as articles about diseases, bulletins, notices, notes, and othermedically-related references. The e-commerce portion of sub-system 36integrates e-commerce capabilities, including business-to-business orbusiness-to-consumer purchasing through shopping cart-type databaseswith affiliated product and service vendors.

The personalization sub-system 38 integrates information from theprevious sub-systems 20, 28, 34, 36 to provide a personalized view ofdata in system 2. Specifically, when any of the participants 13 login tosystem 2 and access data or other information from database sets 4, 6,or 8, or even the content/e-commerce sub-system 36, pertinentinformation derived from the type of content viewed, as well as theproducts purchased or searched, is maintained in a user profile database40. During subsequent logins, therefore, the information a particularuser views can be arranged and accessed in a more familiar, relevant,and useful manner, individual to that participant.

The presentation sub-system 42 manages the normalized data andinformation into a presentable format for participants 13. For example,the world-wide-web, being a popular destination for users of theinternet, accepts output in HTML format, and is accessible by aconventional internet browser. It is appreciated, however, that suchdata may be presented in virtually any form to accommodate differentaccess devices (for example, WAP for mobile devices).

A security sub-system 44 is shown in FIG. 2 integrated with the othersub-systems 20, 28, 34, 36, 38, 42. Security sub-system 44 maintainsdata security in several ways. First, one embodiment contemplates thatthe insurers' 11 data is maintained on its own on-site database, and iscontrolled by the insurers 11. Second, the insurers' 11 data isencrypted when it is routed from the insurers' 11 database to theconnectivity sub-system 20 and, ultimately, the participants 13 when arequest 22 is made. Third, the participants' 13 browser includesencryption to view or send data over the internet 12. Finally, internalsecurity is built into the data processing system 10 to only allow userswith need-to-know access to particular data, such as claims and referralinformation. For example, providers 14 may have access only to claimsand referral information of their insurers, but not individual claimsummaries of their patients. Similarly, the employers 16 may have accessto only their employees' claims information, but not some personalinformation.

An example of an encryption method is the 128 bit Secure Sockets Layer(SSL) with a key certified by VeriSign, Inc. Such SSL encryption meansthat data traveling through the internet and to participants' 13 browsercannot be interpreted by anyone between those two locations. Encryptionis also useful because of the storage of user passwords. There is noplace that a user's password is saved or used by the system astraditional clear text. From one of the participants' 13 browser throughinternet 12 and to one of the insurers' 11 computer or server, thepassword is protected by SSL. Once the password reaches the finaldestined server, a cryptographic algorithm converts the password to aprotected format. No one, therefore, who has privileged access to theserver or any of the back-end applications can get any user passwords.

In addition, encryption is useful along the operative connection to aninsurer's 11 database sets 4, 6, or 8 to the data processing system 10.It is contemplated, however, that insurers' 11 computers or servers(database sets 4, 6, or 8) may not need such encryption along thisoperative connection, if the connection is a true point-to-pointconnection. Also, this encryption can be implemented through hardware orsoftware, a virtual private network (VPN), or through the use ofencryption protocols in a database, for example.

There are several modes with which data can be restricted, even withinand among the insurers 11 and participants 13 of system 2. For example,security sub-system 44 may restrict the actual data that a participant13 may request or view from any of insurers 11. A health careorganization, thus, may only view data that they have provided. Forexample, doctors may only view claim data for their own patients.Alternatively, security sub-system 44 may restrict access toparticipants 13 to allow access to only particular fields on aparticular screen of any particular database. For example, if a screenlisted dollar amounts for claims, employers may wish to restrict who isable to view those dollar amounts. Other users, therefore, like patients18, might be able to see the rest of the claims, but not the dollaramounts. Still, further, security sub-system 44 may restrict whichscreens will be accessible to which users. This level of securitydefines which functionality is available to the user. For example, apatient 18 in system 2 may not be able to view the claim submittalscreen submitted by provider 14 at all, but may view a diagnosisinformation or health plan administrative screen. Customizable securitybased on the interests of the user may be included as well. Thissecurity method allows either the insurers 11 or participants 13 to setthe parameters of security for the examples described above. It isfurther contemplated that this tool may be an internet-based tool thatcould add logins to the system, as well as specify values and screensthat a particular user has access to. It is still further contemplatedthat a portion or all of the security measures can be employedthroughout data processing system 12.

An audit sub-system 46, like security sub-system 44, shown in FIG. 2, isalso integrated with the other sub-systems 20, 28, 34, 36, 38, 42. Auditsub-system 46 tracks the operation of all sub-systems. The informationgenerated from audit sub-system 46 allows an administrator to monitorthe operation of system 2 for problems and marketing trends.

A diagrammatic view of the data extraction and business objectsub-systems 28, 34, respectively, is shown in FIG. 3. As previouslydiscussed, the numerous databases represented by database sets 4, 6, 8contain data in a variety of formats. Before the data is transferred toone of the participants 13, however, it is first formatted to a newformat that is readable by any of the computers of participants 13, likeHTML format, for example. The data is, therefore, “extracted” from thedatabase sets, either 4, 6, or 8, and then “normalized” to be read bythe computers of participants 13. The extracted data is indicated byreference numeral 48.

Extracted data 48 from either database sets 4, 6, or 8 is uploaded to astaging database 50 which is typically a portion of data extractionsub-system 28. Rules engine 52 serves a dual purpose of defining therules that control the normalization of the data, as well as how thedata, once normalized, is used. During the normalization process at 54,rules engine 52 homogenizes the data by determining what the data means,then inserting the data into the proper field as normalized data. Rulesengine 52 also remodels the data, if necessary, to a structure orappearance predefined by the normalized format. As a simple example, ina referrals database that may hypothetically exist on database set 6, itmay include the entry “New Jersey” in the state location field. If thatfield is requested by a participant 13, the rules engine 52 will causethat field to be extracted, then determine whether the meaning of thisfield corresponds to the meaning of the normalized state location field,and, if so, then convert the field to the normalized state locationfield at 58. Furthermore, if the rules engine 52 has predetermined thatthe normalized state location field should exist as only a two-characteracronym, then the phrase “New Jersey” will be remodeled to the acronym“NJ.” This is contrasted with traditional transliterating programs thatwould merely match the state location field of the referrals databasewith any field in another database titled “state location field” andthen transfer the data. Such a program cannot determine the meanings ofthe state location fields, and then determine if their meanings matched,as well as not remodel the data to the appropriate appearance. Forexample, a field for laboratory enzymes might be expressed in Celcius inone database and in Fahrenheit in another database. Such data, as wellas countless other data, are typically contextualized by the system theyexist in. Transliterating programs do not compensate for such contextamong data. In the present disclosure, part of the normalization isdetermining the meaning of the data and locating it in a field of thesame definition, but in a single format.

Rules engine 52 also determines whether the data is bad or invalid. Anybad or invalid data that is discovered during the normalization processat 54 is transferred to an invalid data database 56. Invalid data isplaced in database 56 for review and appropriate corrective action and,if appropriate, reintroduced and normalized.

In addition, the rules engine 52 incorporates security 44 to determinewhether the requestor has authorization to view the data that is beingrequested, as previously discussed. For example, if employer 16 requestsclaims data that illustratively exists on database set 8, the rulesengine 52, in conjunction with the security 44, determines whetheremployer 16 has authorization to view the data subject of that request.If not, rules engine 52 would deny fulfillment of the request.

Once the data is converted and remodeled into the normalized format,rules engine 52 determines how the normalized data can be used. Forexample, if a request 22 is made from providers 14 to one of theinsurers 11 to authorize a chest X-ray for one of the patients 18, aproper response 24 may reference data from various eligibility, claims,benefits, and personal data databases which rules engine 52 firstextracts and normalizes. Once the data is normalized, rules engine 52undertakes the process of responding to request 22. Rules engine 52bases response 24 on predetermined rules established by the particularinsurer 11 to determine whether a chest x-ray is an approved procedurein response to the request. It is contemplated that each insurer 11, oreven each database set 4, 6, 8 can be subject to its own unique set ofrules to govern any particular response 24.

An audit database 62, illustrated in FIG. 3, manages and maintainstracking information during the conversion process at 58. All datarequests, responses, and e-commerce submissions can be monitored andrecorded. This audit trail information is maintained in audit database62 to enhance performance and security characteristics. It iscontemplated that audit database 62 can be integrated with auditsub-system 46, as shown in FIG. 2, or database 62 can be a stand-alonesystem working independently or in addition to sub-system 46.

In one embodiment of the disclosure, it is contemplated that system 2will not only exchange information related to insurance and paymentissues, but also provide active management of patient care. For example,as shown in FIG. 4, a portion of system 2 depicts the process formedical tests to be ordered, approved, and results submitted. Forexample, a health care provider 14, via the internet 12, places an orderfor a medical test. The order is transmitted through data processingsystem 10. The order is further transmitted at 72 to a laboratory 70,the order will disclose particular information that will be needed wheneither the specimen or the patient arrives. If a specimen is collectedby provider 14, the order will identify the laboratory 70, and provideinformation to provider 14 so that the specimen may be markedaccordingly before being sent to laboratory 70. Once laboratory 70receives the order and the specimen, laboratory 70 can eithercommunicate the status or results back through data processing system 10to both the provider 14 and the appropriate insurer 13′, as indicated byreference numerals 74, 76, respectfully. FIGS. 6A-6D show an exampleuser interface for health care providers to order and view medicaltests. FIG. 7 shows an example user interface in which a health careprovider can submit a prescription to a pharmacy over the Internet.

Although the system has been described with reference to particularmeans, materials and embodiments, from the foregoing description, oneskilled in the art can easily ascertain the essential characteristics ofthe illustrative system and various changes and modifications may bemade to adapt the various uses and characteristics without departingfrom the spirit and scope of the present invention as described by theclaims which follow.

1. A method for facilitating an exchange of information between apatient and a health care provider, the method comprising the steps of:providing a patient web portal from which a patient can enter personalhealth date; storing the personal health data entered via the patientweb portal into a database; receiving an access list from the patientvia the patient web portal, wherein the access list is indicative ofaccess rights to a selected portion of the personal health data;receiving a request for the selected portion of the personal health datafrom a health care provider of the patient; detecting whether the healthcar provider has been granted access to the personal health data basedon the access list; and transmitting the personal health data responsiveto the detecting step.
 2. The method of claim 1, further comprising thestep of storing provider data generated by the health care provider inthe database, wherein the provider data is indicative of at least onehealth related parameter of the patient.
 3. The method of claim 2,further comprising the step of enabling the patient to access at least aportion of the provider data via the patient web portal.
 4. The methodof claim 1, wherein the patient data is selected from the groupconsisting of family health history of the patient and over-the-countermedications taken by the patient.
 5. The method of claim 1, furthercomprising the step of auditing access to the personal health data. 6.The method of claim 1, wherein the access list includes a first set ofaccess rights associated with the health care provider, a second set ofaccess rights associated with an insurer of the patient and a third setof access rights associated with an employer of the patent.
 7. A methodfor maintaining a personal health record, the method comprising thesteps of: interacting with a patient web portal to access a databaseover the Internet; entering patient data indicative of at least onehealth related parameter of a patient, wherein the patient enters thepatient data using the patient web portal; storing entered patient datain the database; wherein the patient data includes at least one of:family health history of the patient and over-the-counter medicationstaken by the patient.
 8. The method of claim 7, wherein the database isaccessible by a health care provider of the patient.
 9. The method ofclaim 8, further comprising entering a security list respective toaccess rights to patient data in the database, wherein the patiententers the security list using the patient web portal.
 10. The method ofclaim 9, further comprising the steps of receiving a request from thehealth care provider for access to a requested portion of the patientdata, detecting whether the health care provider has been granted accessto the requested portion of the patient data using the security list,and allowing the health care provider to view the requested portion ofthe patient data responsive to the detecting step.
 11. The method ofclaim 9, further comprising the steps of receiving a request from anemployer of the patient for access to a requested portion of the patientdata, detecting whether the employer has been granted access to therequested portion of the patient data using the security list, andallowing the employer to view the requested portion of the patient dataresponsive to the detecting step.
 12. The method of claim 9, wherein thedatabase includes information provided by a health care provider of thepatient.
 13. The method of claim 12, wherein the database furtherincludes information provided by at least one outpatient facility. 14.The method of claim 13, wherein the outpatient facility is selected fromthe group consisting of a laboratory, radiology, and pharmacy.
 15. Themethod of claim 13, wherein the database further includes informationprovided by at least one inpatient facility.
 16. The method of claim 13,wherein the information provided by the health care provider isdeveloped by extracting health care data from a separate database andnormalizing the extracted data to a predefined format in accordance witha rules engine that defines a plurality of health care data fields in apredefined format and a plurality of relationships between fields ofnormalized data.
 17. The method of claim 13, further comprising the stepof accessing at least a portion of the information provided by thehealth care provider, wherein the patient accesses the informationprovided by the health care provider using the patient web portal. 18.The method of claim 17, wherein the information provided by the healthcare provider includes at least one of: laboratory test results,radiography test results, medication profile, and referral information.19. The method of claim 17, wherein the patient accesses at least one ofthe following types of information provided by the health care providerusing the patient web portal: laboratory test results, radiography testresults, medication profile, and referral information.
 20. The method ofclaim 19, further comprising the steps of receiving an electronicapplication requesting access to at least a portion of the database,wherein the application includes a requested access list and profile anddetermining whether to grant the application.
 21. The method of claim 7,wherein the database includes provider data provided by least at twohealth care providers, patient data entered by the patient via thepatient web portal, and employer data provided by the employer of thepatient.